Patient Name: Patient Tel No:

Patient Address: Date:

March 3, 2023

PERSONAL DETAILS
Age group: Under 20 20 - 30 30 - 40 40 - 50 50 - 60 60+

Lifestyle: Active Sedentary

GP Address: No. Of children (if applicable):

CONTRAINDICATIONS (select if/where appropriate):

Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.

Pregnancy Any dysfunction of the nervous system (e.g. Muscular sclerosis,

Cardio vascular conditions Parkinson’s disease, Motor neurone disease)
Haemophilia Bells Palsy
Any condition already being treated by a GP or another health Inflamed nerve
professional Cancer
Medical oedema Spastic conditions
Osteoporosis Kidney infections
Arthritis Whiplash
Nervous/Psychotic conditions Slipped disc
Epilepsy Undiagnosed pain
Recent operations When taking prescribed medication
Diabetes Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever Abrasions
Contagious or infectious diseases Scar tissues (2 years for major operation and
Under the influence of recreational drugs or alcohol 6 months for a small scar)
Diarrhoea and vomiting Sunburn
Skin diseases Hormonal implants
Undiagnosed lumps and bumps Abdominal pain
Inflammation Haematoma
Varicose veins Hernia
Pregnancy (abdomen) Recent fractures (minimum 3 months)
Cuts Cervical spondylitis
Bruises Gastric ulcers

MEDICAL HISTORY

Respiratory: Gastro Intestinal

COPD- ex smoker Nil

Genito Urinary: Gynaecological:

Nil Nil

Musculoskeletal: Cardio Vascular:

Lower back pain with occasional radiating leg Nil
pain due to a herniated disc. (2020)

Medications: Illnesses:
Various inhalers Nil
 Worse pain Please highlight by using the tool in the ‘drawing markups toolbox’ in the comments menu (top right)
Possible

10
9
8
7
6
5
4
3
2
1

No pain

Aggravating Factors: Relieving Factors:

Prolonged sitting and bending Gentle walking and lying down
Quick movments of spine

Onset:
When: How:
2 weeks ago// Feb 2023 Lifting up groccery bag

Progression: Any Treatment:

Condition remains stable with fluctuations in pain Heat and paracetamol. Found heat more beneficial
intensity

Radiation: Frequency:
Pain occasionally radiates down the back of the Pain increases throughout the day with activities /
right leg. sedentary lifestyle

Character:
Sharp shooting pain
Observation: Active and Passive Movements:
Patient stood with slight level of lumbar and Full AROM into flex / ext.
cervical rounding. EOR extension increases pain.
Reduced AROM (3/4) into R and L L spine
rotation.rotation.

Palpation: Special Tests:

Pain in erector spinae and QL on palpation. Patient neuro Ax: myotomes, dermatomes testing.
tensed up with QL palpation. Slump test, SLR: +

Clinical Opinion for the Complaint:

Soft tissue injury of QL / erector spinae caused from loaded extension into lumbar spine.

Treatment:
Effleurage applied from lower to upper back, focusing on QL and erector spinae. Promotes warming and
vasodilation, aids venous return, and initiates patient contact.
Petrissage techniques utilized to mobilize tissues and enhance blood flow: wringing, muscle compressions,
and open C of QL, kneading into erector spinae with reinforced finger pads.
NMT applied to erector spinae, releasing 2x active trigger points.
Indirect myofascial release across QL to release fascial adhesions.
MET employed for piriformis and glute max to encourage muscle lengthening.

How patient felt after treatment:

Reported that they felt much more mobile.

Home care (FID - frequency, intensity, duration):

Stretch Strengthen Postural Heat Cold

Specific home-care advice:

Heat has proven efficient for pain relief - pt to continue with current routine.
Strengthening of TA and glutes. (Pilates sequence for core and glute bridge exercises provided)
Stretching of piriformis and QL (starting with 10seconds progress as tolerable x 3 / day)

Reflective Practice:
Good subjective assessment resulting in a positive patient outcome.
Acknowledging that soft tissue healing requires time, patient informed about massage's supportive role in
the recovery process but still requires time.
SOAP FORM Follow up No: 1
Patient Name: Date:
March 10, 2023

Worse pain Please highlight by using the tool in the ‘drawing markups toolbox’ in the comments menu (top right)
Possible
10
9
8
7
6
5
4
3
2
1

No pain

Improving No Change Worsening New Contraindications

How patient has been since last treatment: Observation:

Reduced intensity of pain (5/10) Patient exhibited improved posture, showing
reduced lumbar arching during today's session.

Palpation: A & P Movements:

Some tenderness still around QL. Full AROM into flex / ext.
EOR extension increases pain.
Reduced AROM (~10 degrees) into R and L L
spine rotation.

Functional Tests: Treatment Goals:

Nil Reduce some ongoing tenderness in QL and
improve AROM into side flexion and rotation
Treatment:
Effleurage utilized on paraspinals for warming and vasodilation, promoting venous return and initiating
patient contact.
Petrissage applied for tissue mobilization, encouraging increased blood flow: wringing, muscle
compressions, and open C of QL, kneading into erector spinae with reinforced finger pads.
Indirect myofascial release performed on QL to address fascial adhesions.
MET employed for piriformis and glute max to encourage muscle lengthening.
Effleurage of paraspinals and QL to conclude the session, further enhancing venous return.

How patient felt after treatment:

Increased mobility, achieved full range of motion in rotation on both sides. Slight restriction in side flexion
due to tenderness across the QL area.

Patient To Return After:

Day(s) 1 Week(s) Month(s)

Home care (FID - frequency, intensity, duration):

Stretch Strengthen Postural Heat Cold

Specific Home-Care Advice:

Strengthening of TA and glutes. (Pilates sequence for core and glute bridge exercises provided)
Side flexion stretch provided 3x(time as tolerable) 2/day

Reflective practice:

I was able to utilise the previous weeks practice today to further work on the pt. Deeper tissue work was
better tolerated today, and techniques remained similar, with adapted pressure as needed.
SOAP FORM Follow up No: 2
Patient Name: Date:
March 17, 2023

Worse pain Please highlight by using the tool in the ‘drawing markups toolbox’ in the comments menu (top right)
Possible
10
9
8
7
6
5
4
3
2
1

No pain

Improving No Change Worsening New Contraindications

How patient has been since last treatment: Observation:

Continued improvement in back pain(4/10). Patient Posture is much improved. Pt looks visibly more
experiences tenderness across the lower back, relaxed since first session.
especially in QL, during side flexion or heavy
lifting from the floor.

Palpation: A & P Movements:

Some tenderness remains in QL. Deeper palpation FROM ext / flexion / rotation. 10 degrees short of
needed to create this tenderness compared to the side flexion on each side limited by some pain or
last session. learned aprehension to achieve EROM due to pain.

Functional Tests: Treatment Goals:

Nil Ease any remaining tenderness. Boost blood flow
to allow pain-free side flexion.
Treatment:
Effleurage on paraspinals: warming, vasodilation, and venous return.
Petrissage to mobilize tissues: wringing, muscle compressions, open C of QL, kneading into erector spinae.
Indirect myofascial release on QL to release fascial adhesions.
MET on QL for muscle lengthening.
Effleurage on paraspinals and QL to conclude, promoting venous return.

How patient felt after treatment:

Pt was able to access full side flexion range.
Pt felt comfortable to be able to manage back on own with current exercise programme. Pt is able to access
further sessions on an as needed basis.

Patient to return after:

0 Day(s) 0 Week(s) 0 Month(s)

Home care (FID - frequency, intensity, duration):

Stretch Strengthen Postural Heat Cold

Specific Home-Care Advice:

Strengthening of TA (pilates table top sequence provided)
Strengthening of glute max (bridge variations and progressions provided)
Glute med stabilisation exercises including step ups provided.
Side plank series included.

Summary of Patient:

Patient progressed positively from initial acute LBP. Symptoms naturally reduced with massage and heat
therapy, aiding recovery. Started core strengthening program to prevent future reinjury. Happy with
progress, ending sports massage sessions now.

Student Name:
Daniel Vattathichirayil